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METHODICAL INSTRUCTIONS
for practical lesson
« Abnormal »
MODULE 4: Obstetrics and gynecology
TOPIC 5
Aim: to learn the causes, clinic, diagnostic, treatment and preventing measures of abnormalities of
uterine contractions, to learn the biomechanism of labor in breech presentation, recognise the
breech presentation and be able to render the manual assistants in labor in the different types of
breech presentation. To learn how to make the diagnosis of malpresentations. To show the causes
which results in this. To learn the indications, conditions and the techniques for operation of
obstetric versions.
Professional motivation: The breech presentations occur in about 3-4% of all labors. With
breech presentation, compared to cephalic presentation both the mother and the fetus are at
greater risk. The prognosis for the fetus in a breech presentation is considerably worse than when
in a vertex presentation. The operative delivery rate is higher and may be; higher maternal
morbidity and mortality. It is very important to know the biomechanism of labor in breech
presentation and the correct management-1 of labor. Students have to be able to render the
manual aid to avoid the complication coursed by pathological labor.
Malpresentations are very actual obstetrics problem because it results in increasing of maternal
and fetal morbidity and mortality. It is also impossible to manage labors through maternal
passages and needs using of obstetrics operation, in most cases cesarean section.
Contracted pelvis: learning the main types and peculiarities of labor in contracted pelvis gives a
possibility to prevent the main obstetric complications, perinatal and maternal death.
Basic level:
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Obstetrics terminology.
2. External and internal obstetric examination.
3. Segments of fetal head
4. Lower segment of uterine and contraction ring.
5. Signs of normal uterine contractions
6. Conduct of normal labor & delivery and their clinic.
7. Classification of uterine contractions abnormalities.
8. Factors that provide normal uterine contractions.
9. Definition of primary and secondary uterine inertia.
10. Incoordinative uterine activity,
11. Excessive uterine activity.
12. Medicines for correction of uterine contractions.
13. Methods of treatment of uterine inertia in the first and second stages of labor.
14. Prevention of uterine contractions abnormalities.
BREECH PRESENTATION
1. Anatomy of fetal head.
2. Anatomy and topography of the uterus, pelvis and pelvic floor.
3. External and internal examination of pregnant women.
4. The structure of the fetal head.
5. Diameters of the fetal body at term.
6. The stages of the labor.
MALPRESENTATIONS
1. Anatomy and topography of the uterus
2. External and internal examination of pregnant women
3. Methods of diagnostic of different fetal positions.
4. Measuring of external pelvis sizes.
5. Kinds of obstetrics operations, indications and contraindincations for cesarean section,
craniotomy and embriotomy
6. The preoperative preparing of patients. The deflexed vertex presentation — diagnosis, the
cardinal movements of labor, prognosis, the management of labor.
7. The brow presentation — diagnosis, the cardinal movements of labor prognosis, the
management of labor.
8. The face presentation - diagnosis, the cardinal movements of labor, prognosis, the
management of labor.
9. Prognosis and complications of the labor in deflexed presentation.
10. The deforms of the fetal head in deflexed presentation.
11. The methods of operative delivery in deflexed presentation.
CONTRACTED PELVIS
1. Etiology and pathogenesis of abnormal development of pelvis.
2. Sizes of normal pelvis.
3. Principles of dispensary monitoring for the pregnant women with
contracted pelvis.
4. Methods of pregnant and puerpera investigation.
5. Estimation of external and internal pelvic sizes.
6. Clinic and management of physiologic pregnancy and labor.
7. Cardinal moments of labor in flexed and deflexed vertex presentations.
BREECH PRESENTATION
1. Classification of breech presentations.
2. Diagnosis of breech presentations.
3. The biomechanism of the labor in breech presentations.
4. The cardinal movements of labor in breech presentations.
5. The manual aid by Tsovyanov I on the labor in the frank bree< presentation.
6. The classic manual aid on the labor in the complete and incomplete, breech presentation.
7. The manual aid by Tsovyanov II on the labor in the footling breech presentation.
8. The operative delivery in the breech presentation.
9. The complications to the delivery in a breech presentation.
MALPRESENTATIONS
1. The determination of malpresentations.
2. Types oi malpresentations.
3. The making diagnosis of malpresentations, physical and instrumental
methods of investigations.
4. The determination of obstetrics version. Classification.
5. The indications for external obstetrics version.
6. The contraindications and conditions for the operation of extern*
obstetrics version.
7. The indications, contraindications and requirements for the poda"
internal obstetric version.
8. The technique for the operation of the external obstetrics versio
9. The technique for the operation of the internal podalic version
10. Anesthesia for the operations.
1l. The complications caused by obstetrics versions.
12. Management of postoperative period.
CONTRACTED PELVIS
1. Pelvic classification according to form of contractions.
2. Anatomically and clinically contracted pelvis.
3. Diagnosis of contracted pelvis.
4. Pelvic classification according to degree of contraction.
5. Often occurred contracted pelvis: generally contracted pelvis, sial pelvis: simple flat pelvis,
flat rachitic pelvis, generally contracted flat pelvis
6. Principles of pregnancy management in contracted pelvis.
7. Principles of labor management in contracted pelvis.
8. Cardinal moments of labor in different types of contracted pelvis-
9. Vasten's and Zangemeister sign.
Summary
UTERINE BIRTH ACTIVITY ANOMALIES
Birth activity anomaly is the state when frequency, duration, rhythm and force of parodynia
and labor do not provide dynamic, within the physiological parameters of time, advancement of
the fetus and its expulsion without delivery biomechanism violation.
Disorders of any index of uterine activity are possible — uterine tone, rhythm, frequency
and coordination of contractions, intervals between labor pains, delivery duration.
Correct diagnosis and management of abnormal labor requires evaluation of the
mechanisms of labor: in classic terms, the "power," the "passanger,"an the "passage,"
otherwise refferred to as the uterine contractions, fetal factors (e.g., presentation, size), and the
maternal pelvis, respectively: power, or strength, duration and frequency of uterine
contractions, evaluated both qualitatively and quantitatively. Frequency and duration of
contractions can be subjectively evaluated by manual palpation of the maternal abdomen
during contraction. Strength of uterine contractions is often judged by how much the uterine
wall can be "indented" by an examiner's finger during a contraction: strong contraction no
indetation; moderate contraction, some indentation; mild contraction, considerable
indentation. Although subjective, such determinations by experienced examiner are of value.
The frequency and duration of uterine tractions may be measured more accurately by using a
tocodynamometer while performing external electronic fetal monitoring.
For cervical dilatation to occur, each contraction must generate at least 25 mm Hg of
pressure, with 50 to 60 mm Hg being considered the optimal intrauterine pressure. The
frequency of contractions is also important in generating a normal labor pattern; a minimum
of three contractions in a 10- minute widow is usually considered adequuate.
During the first stage of labor, arrest of labor should not be diagnosed until the cervix is at
least 4 cm dilated ( i.e., the latent phase of labor has been completed) and a pattern of uterine
contractions that is adequate both in frequency and intensity has been established.
The early part, or latent phase, of labor is involved with softening and effacement of the
cervix with minimal dilatation. This is followed by a more rapid rate of cervical dilatation,
known as the active phase of labor, which is further divided into acceleration and deceleration
phases.
The descent of the fetal presenting part usually begins during the active phase of labor,
than progresses at more rapid rate toward after the cervix is completely dilated. A useful
method for assessing the progress of labor and detecting abnormalities in a timely manner is to
plot the rate of cervical dilatation and descent of the fetal presenting part.
Normal cervical dilatation and descent of the fetus take place in a progressive manner and
occur within a well-defined time period. Dysfunctional labor occurs when rates of dilatation
and descent exceed these time limits.
The normal limits of the latent phase of labor extend up to 20 hours for nulliparous patients
and up to 14 hours for multiparous patients. A latent phase that exceeds these limits is
considered prolonged and may be caused by hypertonic uterine contractions, premature or
excessive use of sedatives or analgesics, or hypotonic. uterine contractions.
Hypertonic contractions are ineffective, painful and are associated with increased uterine
tone, whereas hypotonic contractions are usually less painful and are characterized by an
easily indictable uterus during the contractions.
Hypotonic contractions occur more frequently during the active phase of labor. A long,
closed, firm cervix requires more time to efface and to undergo early dilatation than does a
soft, partially effaced cervix, but it is doubtful that a cervical factor alone causes a prolonged
latent phase. Some patients who appear to be developing a prolonged latent phase are shown
eventually to be in false labor, with no progressive dilatation of the cervix.
Palpation or recording of uterine contractions and observation of the patient over a period
of time usually suggests whether uterine activity is hypotonic or hypertonic or whether the
patient is in false labor.
The management of a prolonged latent phase depends on its cause. A prolonged latent
phase caused by premature or excessive use of sedation or analgesia usually resolves
spontaneously after the effects of the medication have disappeared. Hypertonic activity
responds erratically to oxytocin but usually responds to a therapeutic rest with morphine
sulfate or an equivalent drug.
Hypo contractile dysfunction usually responds well to an intravenous oxytocin infusion.
When the cervix dilates to approximately 3 to 4 cm, the rate of dilatation progresses more
rapidly. Cervical dilatation of less than 1.2 cm/hour in nulliparous women constitutes a
protraction disorder of the active phase of labor. During the latter part of the of the active
phase, the fetal presenting part also descends more rapidly through the pelvis and continues to
descend | through the second stage of labor. A rate of descent of presenting part of less than l.0
cm/hour in nulliparous women and 2.0cm/hour in multiparous women is considered to be a
protraction disorder of descent.
During the second stage of labor, the "powers" include both the uterine contractile forces
and voluntary maternal expulsive efforts (pushing). Maternal exhaustion, excessive anesthesia,
or other conditions such as cardiac disease or neuromuscular disease may already affect these
combined forces so that they are insufficient to result in vaginal delivery or cesarean section
may then be required.
In the absence of cephalopelvic disproportion or fetal malposition, protraction or arrest
disorders are usually caused by hypotonic uterine; contractions, conductions anesthesia, or
excessive sedation.
A prolonged latent phase can be managed by either rest or augmentation of labor with
intravenous oxytocin once mechanical factors have been ruled out. If the patient is allowed to
rest, one of the following will occur; she will cease having contractions, in which case she is
not in labor; she will go into active labor; or she will continue as before, in which case
oxytocin may be administered to augment the uterine contractions. The use of arnniotomy, or
artificial rupture of membranes, is also advocated [or patients with prolonged latent phase.
During the active phase of labor, mechanical factors such as fetal malposition and
malpresentation as well as fetopelvic disproportion must be considered before augmentation
of uterine contractions with oxytocin. In cases in which the fetus fails to descend in case of
adequate contractions, disproportion is likely and cesarean section warranted. If no
disproportion is present, oxytocin can be used if uterine contractions are judged to be
inadequate. In cases of maternal exhaustion resulting in secondary arrest of dilatation, rest
followed by augmentation with oxytocin is often effective.
BREECH PRESENTATION
There is a fundamental difference between delivery in cephalic and breech presentation. With a
cephalic presentation, once the head is delivered, typically the rest of the body follows without
difficulty. With a breech, however, successively larger or, in case of the head, very much less
compressible parts of the fetus are born.
Spontaneous complete expulsion of the fetus that presents as a breech, as described below, is
seldom successfully accomplished. As the rule, either cesarean section of vaginal delivery that
requires skilled participation by the obstetrician is essential for a favorable outcome.
Etiology. Breeches are much more common at the end of the second trimester of pregnancy than
at or near term. Factors other than prematurity that arrear to predispose to breech presentation
include uterine relaxation association with great parity,multiple
fetuses,hydramnion.hydrocephalus, anencephalus, previous breech delivery, uterine anomalies,
and tumors.
Classification. The varying relations between the lower extremities and buttocks of the fetus in
breech presentation form the categories of frank breech, complete breech, incomplete breech
presentation, footling and kneeling presentation.
In frank breech presentation the lower extremities are flexed at the hips and extended at the
knees and thus the feet lie in close proximity to the head.
In complete breech presentation the lower extremities are flexed at hips and at the knees.
In incomplete breech presentation the lower extremities are flexed at nips and at the knees and
the one or both feet lie below the breech. »n footling presentation the feet lies lower than breech.
1 tie kneeling presentation is the especial form of the breech, when the fetal knees are lower than
the breech.
Diagnosis. The diagnosis of the breech presentation may be making 'he help of external and
internal obstetrics investigation. With the first maneuver of the external examination we identify
the hard, round ballottable fetal head to occupy he fundus of the uterus. The second maneuver
indicates the back to be on one side of the abdomen and the small parts in other. On the third
maneuver the breech is movable above the pelvic inlet. The heart sounds of the fetus are usually
heard loudest slightly above the umbilicus.
Vaginal examination. In frank breech presentation only buttocks and its characteristics
components (both ischial tuberosities, the sacrum, the anus, the external genitalia) are usually
palpable. In incomplete breech presentation the buttocks and the feet may be palpated. In
footling the fetal feet are lower than buttocks.
Biomechanism of labor in breech presentation,
I moment - the internal breech rotation. The breech rotates and fetal intertrochanteric diameter
from one of oblique size of the pelvic inlet to anteteroposterior size of the pelvic outlet.
II moment - the lateral flexion of the body. The anterior hip is stemmed against the pubic arc. By
lateral flexion of the fetal body the posterior hip is forced over the anterior margin of the
perineum. Then anterior hip is born.
III moment - the internal shoulders rotation. Alter the birth of the breech, there is the slight
external rotation as a result of the descends and rotations of the shoulders. The shoulders rotates
on the pelvic floor and. diameter biacromialis occupies anteroposterior diameter of the pelvic
outlet.
IV moment - the lateral flexion the body in the thoraco-brachial part. The shoulders are born.
V moment - the internal rotation of the head. The rotation begins when the fetal head descends
from the plane of greatest pelvic dimensions, to the least pelvic dimensions (midpelvis). The
rotation is complete when the head reaches the pelvic floor, the sagittal suture is in the
anteroposterior diameter of the pelvic outlet and the small fontanel is under the symphysis
VI moment - the flexion of the fetal head. The head fixes with its, fossa suboccipitalis to the
inferior margin of symphysis pubis and flexes. The face,forehead,vertex,and occiput are born.
The classic manual aid on the labor in complete and incomplete breech presentation.
The aim of the classic manual aid: to help of the shoulders and the head delivery.
The classic manual aid begins when the lower angular of the anterior scapula became visible.
There are 4 moments of the classic manual aid.
I moment - the delivery of the posterior arm. The posterior shoulder must be delivered first. The
feet are grasped in one hand and drawn upward over the groin of the mother toward which the
ventral surface of the fetus is directed; in this manner, leverage is exerted upon the posterior
shoulder, which slides out over the perineal margin, usually followed by the arm and hand.
II .and III moment - the external trunk rotation and removal of the posterior arm The aim of this
moment is the reverse of the anterior shoulder to the sacrum and the delivery of second arm. The
obstetrician applies his hand on the lateral sides of the fetus trunk and rotates it. The direction of
the movement must be in this way: the occiput must go under the symphysis pubis. When the
posterior shoulder and arm appears at the vulva the doctor put two fingers into the vagina, the
fingers passed along the humorous until the elbow is reached. The fingers are now used to splint
the arm, which is swept downward and delivered through the vulva.
IV moment - delivery of the head. After the shoulder' are born, th head usually occupies an
oblique diameter of the pelvic with the occiput directed anteriorly. The fetal head may then be
extracted by the method of Mauriceau-Levret. Employing the Mauriceau-Levre maneuver to
help flex head, the doctor's middle finger of one hand are applied into the fetal mouth, while the
fetal body rests upon the palm of the hand and fore arm, which is straddled the fetal legs. Two
fingers of the operator's other hand are then hooked over the fetal neck and grasping the
shoulders, downward
traction is applied until the suboccipital region appears under the symphysis.
The body of the fetus is then elevated toward the mother abdomen, and mouth, nose, brow and
the occiput emerge over the perineum. Gentle traction should be exerted by the fingers over the
shoulders.
MALPRESENTATIONS
The transverse lie is the condition when the long axis of the fetus is approximately perpendicular
to that of the uterus. When it forms an acute angle, an oblique lie results. An oblique lie is
usually only transitory, however, for either a longitudinal or transverse lie commonly results
when labor supervenes. For this reason, the oblique lie is termed unstable lie.
An unstable lie is one in which the presenting part alters from week to week. It may be either a
transverse or oblique lie or possibly a breech presentation. These are relatively uncommon events
but are found in association with the following conditions:
1. Grand muitipara. This is by far the commonest factor, due to the lax uterine and abdominal
walls, which prevent the splinting effect found in women with lesser parity.
2. Poiyhydramnios. The volume of fluid distends the uterus and allows the fetus to swim like a
goldfish in a bowi — often taking up an oblique or transverse lie.
3. Prematurity. Here there is a relative excess of fluid to the fetus. If preterm labour occurs, the
fetus may be found to have a transverse lie.
4. Subseptate uterus. The septum prevents the fetus from turning in utero.
5. Pelvic tumors such as fibroids and ovarian cysts may not only prevent the lower pole from
engaging, but cause it to take up a transverse lie.
6. Placenta praevia. This usually prevents engagement of the presenting part. Because of this it
may present with the fetus in an oblique or transverse lie.
7. Multiple pregnancies may present with a transverse lie. If this occur, it is more common in the
second twin.
Diagnosis of the transverse and oblique lies: 1- The external inspection shows than the
abdomen is unusually wide from side to side, whereas the fundus of the uterus extends scarcely
above the umbilicus. On palpation, with the first maneuver no fetal pole is detected. On the
second maneuver, a ballottable head is found in one side and the breech in other. The third and
fourth maneuvers are negative unless labor is vvoii advanced and the shoulder has become
impacted in the pelvis. When the fetal head is situated in the left side of the uterus th first
position of the fetus is identified. When the fetal head is situated h the right side of the uterus the
second position is recognized. On vaginal examination, in the early stages of labor, the side of
the thorax, if it can be reached, may be recognized above the pelvic inlet. When the dilatation is
further advanced, the scapula and the clavicle are distinguished on opposite sides of the thorax.
Later in the labor, the shoulder becomes tightly wedged in the pelvic canal, and a hand and arm
frequently prolapse into the vagina and through the vulva.
Management of transverse and oblique lie. It is not uncommon for the fetus to have a
transverse lie until about the 32nd week of pregnancy If the transverse lie persists after this time
a cause should be determined. An ultrasound examination should be done to exclude placenta
praevia, ovarian tumor or fibroid and if either of these conditions are present an elective cesarean
section should be performed at 38-39 weeks of gestation. The ultrasound is also used for
identifying twins and a subseptate uterus, whilst a vaginal examination will confirm a pelvic
tumor.
The main risk of a transverse or oblique lie is in association with preterrn rupture of the
membranes and cord prolapse. When diagnosed the state of the cervix should be checked. If the
cervix is dilated, the patient should be admitted to hospital. If, however, the cervix is closed and
the membranes are intact the patient may be reviewed on a regular basis. If no easily identifiable
cause is found, attempted external cephalic version can be made after 34 weeks. In grand
multipara patients,the fetus will usually turn easily but will often swing back to an abnormal lie.
If the abnormal lie persists or constantly reoccurs, the woman should be admitted to hospital by
the 38th week. If external version is successful at this stage and the patient's cervix is favorable
then artificial rupture of the membrane can be performed with the head held over the pelvic brim
and an oxytocin drip commenced to augment uterine activity. If the cephalic presentation is
maintained, labor may be allowed to continue. If the transverse or oblique lie reoccurs in labor
then a cesarean section must be performed. Complications of a transverse lie. If a mother goes
into labor with a transverse or oblique lie,several catastrophes may occur. Because this occurs
more commonly in multiparous women and their uterine activity is often much stronger, rupture
of the uterus is more likely. When the membranes rupture there is a greatly increased danger of
cord prolapse-
Obstetrics versions
Operations for correction of abnormal lie or presentation of fetus as obstetrics versions. There
are two types of obstetrics versions: external and internal podalic version. Indications for
obstetrics versions: fetal malpresentations (breech, transverse and oblique lie).
Contraindications. Complicated pregnancy, multifetal pregnancy, ngenital uterine anomalies,
placenta previa, feto-pelvic disproportion.
Conditions: for the external version - 32-36 weeks, intact merribranes, normal movement of the
fetus in the uterus, satisfactory fetal and mother condition; for the internal podalic version -
cervix must be fully dilated, intact or just rupture membranes, normal movement of the fetus in
the uterus, satisfactory mother condition, absence of fetopelvic disproportion.
The internal podalic version consists of such moments:
1. Inserting a hand into uterine cavity.
2. Finding a foot.
3. Grasping one foot.
4. Drawing foot through the cervix while exerting pressure transabdominally in the opposite
direction on the upper portion of the body.
The version is finished when fossa poplitea of the grasping foot in presented in the pudendal
cleft.
DEFLEXED PRESENTATIONS
There are 3 types of deflexed presentation — deflexed vertex, brow and
face presentation.
Etiology. The causes of deflexed presentation are manifold, there are the factors that Savors
extension or prevents flexion the head. Extended position of the head occur more frequently
when the pelvis is contracted or fetus is very large. In multiparous women the pendulous
abdomen predisposes to deflexed presentation. In exceptional instances, marked tumors of the
fetal neck or coils of cord about the neck may cause extension. Anencephalic fetus present by the
brow or face because of faulty development of the cranium.
The deflexed vertex presentation. The deflexed vertex presentation is a I degree of head
extension.
Diagnosis. The diagnosis of the deflexed vertex presentation bases on the results of the vaginal
palpation: the sagittal suture, the large and the small iontanels on the same level. The fetal head
presents with a ironto-occipital diameter,a leader point is the large fontanei.
The cardinal movements of labor in deflexed vertex presentation arc:
• deflexion;
• internal rotation;
• flexion;
• extension;
• internal rotation of the fetal body and external rotation of the fetal head. Deflexion. The
sagittal suture is in the transverse or oblique
size of the pelvic inlet. The head fixes to the inlet and some deflexed. The large fontanel
becomes the leader point.
2. Internal rotation. This movement is a manner that the occiput gradually moves from its
original position posteriorly towards the sacrum os. The rotation is complete when the head
reaches the pelvic floor; the sagittal suture is in the anteroposterior diameter.
3. Flexion of the head. Flexion begins when the head fixes by its root of the nose (the first
fixing point) to the inferior margin of symphysis pubis. The flexion finishes when the occiput
comes to the tip of sacrum and the second fixing point forms.
4. Extension of the head. After internal rotation and flexion the fetal head closely touched
with the area of the occiput to the tip of the sacrum. The head extends and deliveries.
Internal rotation of the fetal trunk and external rotation of fetal head. This moment realizes as
in anterior occiput presentation. The brow presentation is a II degree of extension. With the
brow presentation, that portion of the fetal head between the bital ridge and the frontal suture
presents at the pelvic inlet. The fetal 0 d thus occupies a position midway between full flexion
(ociput) and E II extension (mentum or face). Except when the fetal head is very small the pelvis
is unusually large, engagement of the fetal head and subsequent cannot take place as long as the
brow presentation persists.
Diagnosis. The diagnosis of the brow presentation bases on the results of the external obstetrics
examination and vaginal palpation. The brow presentation may be recognized by abdominal
palpation when both the occi put and chin can be easily palpated. The reliable information can be
felt by the vaginal examination: the frontal suture, the large fontanel, orbital ridges, eyes, and
root of the nose. The nose and mouth can not be palpable.
The fetal head presents with a mento-occipital diameter, a leader point is the middle of the
frontal suture.
The delivery at term in brow presentation is impossible. The preterm delivery, when the fetus is
small is possible and the characteristically deforms of the head occurred. The caput succedaneum
is over the fore head and may be so extensive that identification of the brow by palpation is
impossible.
If the labor is possible the cardinal movements in brow presentation are:
1. Deflexion. The frontal suture is in the transverse size of the pelvic inlet. The head fixes to the
inlet and deflexed. The middle of the irontal suture becomes the leading point.
2. Internal rotation.
3. Flexion of the head.
4. Extension of the head.
5. Internal rotation of the fetal trunk and external rotation °f the fetal head
Face presentation.
In the face presentation.the head is hyperextended so that the occiput is in contact with the fetal
back and the chin (mentum) is presenting part.
Diagnosis. By abdominal palpation the occiput, the chin and the angle between the fetal back
and the occiput can be easily palpated. The 'e'al heart sound are the loudest from the side of the
fetal thorax. On palpation, the distinctive features of the face presentation are the nose, the malar
bones, and the orbital ridges. Face presentation is rarely observed above the pelvic inlet. The
brow ;.Ue y presents and is converted to a face presentation after further extension of the head
during descent through the pelvis.
CONTRACTED PELVIS
Anatomically contracted pelvis is characterized by shortening of
one diameters of the true pelvis into 1,5 - 2 cm and more. Clinically or functional contracted
pelvis is usually defined as jviS with normal dimensions, but vaginally delivery is impossible due
to "fetopelvic disproportion".
The main causes of "cephalopelvic disproportion" are fetal macrosomia, postdate pregnancy,
uterine inertia, fetal malpresentation, especially fetal head extension — sinciput vertex,brow,face
anterior position, ninic signs of clinically contracted pelvis:
1. Head is arrested in the pelvic inlet (absence of fetal descending in complete cervical dilation
and adequate uterine contractions).
2. Uterine contractions abnormality.
3. Positive Vasten' sign (if disproportion between fetal head and symphisis pubis is prominent —
Vasten' sign is positive, if disproportion between fetal head and symphisis pubis is absent -
Vasten' sign is negative).
4. Signs of urinary bladder compression.
5. Edema of the cervix, and vaginal walls, productions of fistulas. When the presenting part is
firmly wedged into the pelvic inlet but
does not advance for a considerable time, portions of the birth canal lying between it and the
pelvic wall may be subjected to excessive pressure. As a circulation is impaired, the resulting
necrosis may become manifest several days after delivery by the appearance of vesicovaginal,
vesicocervical, or rectovaginal fistulas.
6. Danger of uterine rupture.
When the disproportion between the head and the pelvis is so pronounced that engagement and
descent do not occur, the lower uterine segment becomes increasingly stretched, and the danger
of its rupture ecornes imminent. In such cases, a pathologic contractile ring may form and can
be felt as a transverse or oblique ridge extending across
e uterus somewhere between the symphysis and the umbilicus. Whenever condition is noted,
prompt cesarean delivery must be employed to prevent rupture of the uterus.
'- Pushing occurs if fetal head is situated in the plane of inlet. In the case of clinically contracted
pelvis - only cesarean section.
Pelvic classification according to form of contractions:
1. Often occurred
• generally contracted pelvis;
• flat pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted.
Generally contracted pelvis is characterized by diminution of true pelvic diameters
(anteroposterior, transverse, and oblique) into 2 cm. Subpubic arch is narrow. Average sizes of
the pelvis are: D. spinarum - 23cm, D. cristarum - 26 cm. D. trochanterica - 29 cm, C. externa -
ig cm, C. diagonalis — 11 cm, C. vera — 9 cm. Course of labor:
• prolongation of labor;
• considerable fetal head flexion thanks to which it is elongated in the ocipitofrontal diameter
(dolichocepaly);
• posterior fontanel is situated into the axis of pelvis;
• considerable molding of the fetal head. Caput succedaneum is formed in the area of posterior
fontanel;
• with increasing narrowing of the pubic arch, the occiput cannot emerge directly beneath the
symphysis pubis but is forced increasingly farther down upon the ishiopubic rarni. It may play an
important part in the production of perineal tears.
Management of labor. Vaginaliy delivery is possible.
Flat pelvis - is usually defined as diminution of anteroposterior diameters of true
pelvis,transverse and oblique diameters are normal.
Simple flat pelvis is defined as shortening of anteroposterior diameters at all levels of true
pelvis, as a result of this sacrum is inclined anteriorly to pubis.
Average sizes of the pelvis are: D. spinarum - 26cm, D. cristarum ~ 29 cm. D. trochanterica - 31
cm, C. externa - 18 cm, C. diagonalis - H cm, C. vera - 9 cm.
Course of labor:
• prolongation of labor;
• sagittal suture of the fetal head arresting in the transverse diarnetei
of the plane of inlet;
• fetal head extension until bitemporal fetal head diameter would W situated in the
anteroposterior diameter of the plane of inlet;
• anterior fontanel is the leading point of the fetal head (lowermost situate"'1
• asynclitism should be presented (anterior or posterior);
• considerable molding of the fetal head. Caput succedaneum is iorme in the area of anterior
fontanel.
Course of labor is the same as in the simple flat pelvis. But thanks to normal or even increased
anteroposterior size of pelvic outlet perineal tears as result of quick second stage labor may be
presented.
Management of labor. Vaginal delivery is possible.
Generally contracted flat pelvis is characterized by combination of the signs of generally
contracted and flat pelvis.
Average sizes of the pelvis are: D. spinarum — 24cm, D. cristarum — 25 cm., D. trochanterica -
28 cm, C. externa - 16 cm, C. diagonalis - 9 cm, C. vera — 7 cm.
Course of labor depends from predominance of kind of pelvis contraction.
Management of labor. Cesarean section is the method of choice.
WOUND INFECTION
Wound infection appears as a result of the infection of scratches, fissures,
ruptures of the neck, mucous tunic of the vagina and vulva, wounds after excision
of the perineum, anterior abdominal wall after cesarean section.
Inflammatory reaction is characterized by such general clinical
manifestations:
— local inflammatory reaction: pain, hyperemia, edema, local temperature
rise, malfunction of the injured wound;
— generalized reaction of the organism: hyperthermia, intoxication signs
(general weakness, tachycardia, ABP decrease, tachypnoe).
Diagnostics takes into account the following data:
— clinical: examination of the injured surface, assessment of the clinical
presentation, complaints, anamnesis;
— laboratory: common blood analysis (leucogram), common urine
analysis, bacteriological investigation of the exudate, immuno-grara;
— instrumental: US.
Clinical signs of wound infection development in the wounds healing by
primary intention:
a) complaints:
— of intensive, often throbbing pain in the region of the wound;
— of body temperature rise — subfebrile or to 38—39 °C;
b) local changes:
— hyperemia around the wound without positive dynamics;
— appearance of tissue edema, which gradually increases;
— palpation detects tissue infiltration, which often increases; appearance of
deep infiltrates is possible (necrotizing fasciitis, which may spread to the buttocks,
anterior abdominal wall — often a fatal complication);
— serous exudate often changes to pus.
Clinical signs of wound infection development in the wounds healing by
secondary intention:
— progressing edema and infiltration of the tissue around the wound;
— appearance of dense painful infiltrates without clear contours;
— signs of lymphangitis and lymphadenitis;
— wound surface is covered with continuous fibrinopurulent incrustation;
— deceleration or cessation of epithelization;
— granulations become pail or cyanotic, their hemorrhagic diathesis
sharply decreases;
— exudate quantity increases, its character depends on the agent:
• staphylococcus conditions the appearance of thick yellowish pus, and
some strains cause the development of local putrid infection with the formation of
the foci of tissue necrosis and grayish pus with sharp smell;
• streptococcus is characterized by the appearance of liquid pus of yellow-
green color, ichor;
• colibacillary and enterococcal infections condition the appearance of
brown pus with characteristic smell;
• blue pus bacillus, Pseudomonas aeruginosa, leads to the appearance of
green pus with specific smell.
The type of the agent also defines the clinical course of wound infection:
• staphylococcosis is characterized by the fulminant development of the
local process with evident manifestations of purulo-resorptive fever;
• streptoroccosis has a tendency to diffuse spread in the form of phlegmon,
with low-grade local symptoms;
• blue pus bacillus is characterized by the flaccid, protracted course of the
local process after acute onset with evident manifestations of general intoxication.
Bacteriological investigation of exudate is conducted with the purpose of
detecting the agent and its sensitivity to antibiotics. Material sampling is to be
performed before the beginning of antibiotic therapy. Material for the investigation
may be the exudate, pieces of tissue, lavage from the wound. Material is taken with
sterile instruments and placed in sterile tubes or vials with standard medium. Ma-
terial is to be inoculated in the course of 2 h after sampling. Simultaneously with
material sampling for bacteriological investigation one should perform not less
than two Gram-stained smears for express-diagnostics.
There may be used accelerated methods of identifying the wound infection
agent with the help of multimicrotest systems, lasting 4— 6h.
In the absence of microbal growth in the clinical material one should
exclude such reasons:
— presence of high concentrations of local or systemic antibacterial
preparations in the material;
— violation of the regimen of specimen storage and transportation;
— procedural mistakes in the bacteriological laboratory; effective control
over the infectious wound process with antibacterial preparations.
You will find the US technique in the chapter Fetal Condition Imaging and
Assessment except for fact that the sensor is placed on the lesion area in order to
image the infiltration process.
Treatment: in most cases local treatment is sufficient. The treatment includes
surgical, pharmacological, and physiotherapeutic methods.
Surgical wound treatment The initial handling of the wound is performed by
primary indications. Repeated initial handling is performed if the first surgical
intervention was not radical for some reason and repeated intervention was
necessary before the development of i nfectious complications in the wound.
Surgical treatment of wound consists in:
— removal of dead tissue -- primary necrosis substrate — from the wound;
— removal of hematomas (especially deep ones), foreign bodies;
— final arrest of bleeding;
— restoration of damaged tissues.
Secondary treatment of the wound is carried out by secondary indications, as
a rule, in connection with pyoinflammatory complications of the wound. Repeated
secondary treatment of the wound at severe forms of wound infection may be
conducted iteratively. In most cases secondary surgical treatment of wound
includes:
— removal of the focus of infectious-inflammatory alteration; wide opening
of recesses, leakages;
— full-blown drainage providing exudate outflow.
The pharmacological method is antibiotic prophylaxis and antibiotic therapy.
Antibiotic prophylaxis is systemic administration of an antimicrobial
preparation till the moment of microbial contamination of the wound or
development of postoperative wound infection, and also if there are signs of
contamination, on the condition that primary treatment is surgical
Antibacterial prophylaxis principles:
— predominately a single dose of an antimicrobial preparation, in case of
long-term anhydrous period and other risk factors of infectious complications
development one should resort to full-blown prophylactic doses;
— at noncomplicated cesarean section the first dose of antibiotic is
introduced after clipping the umbilical cord and then twice more with an interval of
6 h;
— the same preparation may be used for antibiotic therapy in case of
complications arising during surgery or infectious process signs detected;
— prolongation of antibiotic introduction after 24 h from the moment of
surgery termination does not lead to any increase of the efficiency of wound
infection prophylaxis;
— preterm prophylactic administration of antibiotics before surgical
intervention is not expedient.
Antibiotic therapy is the usage of antibiotics for long-term treatment in case
of infectious process onset. Antibiotic therapy may be:
— empirical — based on the usage of broad spectrum preparations, active
relative to potential agents;
— object-orientated — preparations are used according to the results of
microbiological diagnostics.
Local application of antiseptics is very important. For wound cleansing one
can use 10 % solution of sodium chloride, 3 % hydrogen peroxide, 1:5,000
furacilinum solution, 0.02 % chlorhexidme solution, etc. For quicker healing one
may use liners with levomecol, levosin, synthomycin or solcoseryl ointment, etc.
Physiotherapeutic procedures in the period of reconvalescence include UHF-
inductotherapy, ultraviolet irradiation, electrophoresis with medicamental
preparations.
Prophylaxis of wound infection consists in rational management of labor and
puerperal period, observance of aseptics and antiseptics.
POSTNATAL ENDOMETRITIS
Postnatal endometritis is inflammation of the superficial layer of
endometrium. Endomyoinetritis (metroendometritis) is the spread of inflammation
from the basal layer of endometrium to mvometrium. Perimetritis is the spread of
inflammation from the endometrium and myometrium to the serous uterine layer.
The initial stage of postnatal infectious process may have different intensity
and polymorphous presentation. One should differentiate classical, obliterated and
abortive forms of endomyometritis, endornyometritis after cesarean section. The
classical form usually develops on the 3rd ~5th day after delivery. This form is
characterized .by fever, intoxication, psyche alteration, evident leucocytosis with
leucogram shift to the left, pathological discharge from the uterus. At. the
obliterated form of endomyometritis disease usually develops on the 8 th-9th day
after delivery, temperature is subfebrile, local rnanifestations are low-grade. The
abortive form has a course similar to the classical form, but is quickly arrested at a
high level of immunologic;il protection. Endomyometritis after cesarean section is
often complicated with pelviperitonitis, peritonitis, which may develop during the :
1st—2nd day after the surgery.
Diagnostics is based on:
— clinical data: complaints, anamnesis, clinical examination. Vaginal
examination shows the moderately sensitive uterus, subinvolution of the uterus,
purulent discharge;
— laboratory data: common blood count (leucogram), common urine
analysis, bacteriological and bacterioscopic investigation of the cervical and
uterine discharge (urine and blood if it is necessary), immunogram, blood
biochemistry;
— instrument data: US.
Treatment: in most cases the treatment is pharmacological, but surgical is
also possible.
Complex treatment of postnatal endomyometritis includes not only systemic
antibacterial, infusion, detosication therapy, but also local treatment. Antibiotic
therapy may be empirical and object-orientated (see above). Preference is given to
object-orientated antibiotic therapy, which is possible by using accelerated
methods of agent identification (using multimicrotest system). If fever lasts during
48—72 h after treatment beginning, one should suspect resistance of the agent to
the applied antibiotics. Treatment with intravenous antibiotics is to last for 48 h
after disappearance of hyperthennia and other symptoms. Tableted antibiotics are
to be administered for 5 more days. Antibiotics get into the maternal milk in small
doses. In most cases it does not lead to clinically significant consequences.
Nevertheless, the immature ferment system of the newborn may not manage the
complete excretion of antibiotics, which may cause a cumulative effect.
Local endomyometntis therapy consists in aspiration-washing drainage of
the uterine cavity with the application of a dual-lumen catheter, through which the
uterine walls are irrigated with solutions of antiseptics, antibiotics. There are used
cooled to +4° C solutions of 0.02 % furacilinum, 0.02 % chlorhexine, 0.9 %
isotonic solution with the speed of 10 ml/min. Contraindications to aspiration-
washing drainage of the uterine cavity are: inconsistency of sutures on the uterus
after cesarean section, infection spread beyond the uterus, up to 3—4 days of
puerperal period. If it is not possible to wash the pathological inclusions in the
uterine cavity by means of drainage, they are to be removed by vacuum aspiration
or careful curettage against the background of the conducted antibacterial therapy
and normal temperature if it is possible. Correct treatment of postnatal endomyo-
metritis makes the basis of the prevention of widespread forms of infectious
diseases in parturient women and their localization at the first stage.
Surgical treatment consists in laparotomy and extirpation of the uterus
without the appendages or extirpation of the uterus with, the uterine tubes, or with
the appendages, depending on the spread of the inflammatory process. Surgical
treatment is resorted to in case of conservative treatment inefficiency and presence
of negative dynamics during the first 24—48 h of treatment, development of
systemic inflammatory response symptom (SIRS).
LACTATIONAL MASTITIS
Lactational mastitis is inflammation of the mammary gland (mostly
unilateral) during lactation in the puerperal period. It develops more frequently in 2
—3 weeks after delivery.
Most frequently the portal entry of infection is nipple cracks, in-
tracanalicular penetration of the infectious agent through the mammary ducts at
breast feeding or expression of breast milk; the spread of the agent from
endogenous foci is very rare.
Risk factors:
— nipple cracks;
— lactostasis.
Nipple cracks may take place at nipple malformations, late beginning of
breast feeding, irregular feeding technique, feeding lasting longer than 20 min,
rough expression of milk, individual lability of the epithelial nipple cover,
violation of the sanitary-hygienic standards of the puerperal period.
At lactostasis body temperature rise may last up to 24 h, if longer than 24 h
— this condition is to be considered mastitis.
By the character of the inflammatory process course mastitis can be: serous;
infiltrative; suppurative; infiltrative-suppurative, diffuse, nodular; suppurative
(intramammary): areola furunculosis, areola abscess, abscess in the gland
thickness, abscess behind the gland;
— phlegmonous, purulo-necrotic; gangrenous.
By focus localization mastitis can be: subcutaneous, subareolar, in-
tramammary, retromammary and total.
The clinical presentation of mastitis is characterized by acute onset, evident
intoxication (general weakness, headache), body temperature rise to 38—39° C,
chill, pain in the region of the mammary gland increasing at feeding or expression.
The mammary gland expands, hyperemia and tissue infiltration without clear
margins are marked. This picture is characteristic of serous mastitis. If treatment is
ineffective, serous mastitis develops into infiltrative during 1—3 days. Palpation
detects dense, sharply painful infiltrate, lymphadenitis. This stage lasts 5—8 days.
If the infiltrate does not resolve against the background of the treatment being
conducted, its suppuration takes place — suppurative mastitis (intramammary).
Intensification of local inflammation symptoms is observed, considerable increase
and deformation of the mammary gland; if the infiltrate is located not at a great
depth, suppuration is accompanied by fluctuation. Infiltrate suppuration takes place
during 48—72 h. If a couple of infiltrates have suppurated in the mammary gland,
mastitis is called phlegmonous. Body temperature is 39-40 °C, chills, evident
weakness, intoxication. The mammary gland is sharply enlarged, painful, pastose,
well-marked surface venous network, the infiltrate occupies almost the whole
gland, the skin above the damaged area is edematous, lustrous, red with a bluish
tint, often with lymphangitis. At phlegmonous mastitis infection generalization
with transition into sepsis is possible. Diagnostics is based on:
— clinical data: examination of the mammary gland (see in the text),
assessment of clinical presentation, complaints and anamnesis;
— laboratory: common blood analysis (leucogram), com in on urine
analysis, bacteriological and bacterioscopic investigation of the exudate,
immunogram, coagulogram and blood biochemistry;
— instrument findings: US is the main method of mastitis diagnostics.
Treatment may be conservative and surgical.
Antibiotic therapy should be started from the first signs of the disease, which
promotes the prevention of suppurative inflammation development. At serous
mastitis the question of breast feeding is decided individually. One should take into
account: opinion of the parturient woman, anamnesis (for instance, suppurative
mastitis in the anamnesis, multiple scars on the mammary gland, mammary gland
prosthetics), antibiotic therapy, which is being conducted, the data of
bacteriological and bacterioscopic investigations, nipple crack presence and
evidence. Beginning from infiltrative mastitis breast feeding is contraindicated
because of a real threat of child's infection and cumulative accumulation of
antibiotics in the child's organism, but lactation may be preserved by means of
breast milk expression. If conservative mastitis therapy is ineffective, surgical
treatment is administered during 2—3 days. Surgical treatment consists in radical
section, removal of the necrotized tissues and adequate drainage. At the same time
antibiotic, disintoxication, and desensitizing therapy is being conducted. Timely
surgical treatment allows preventing the development of the process and SIRS.
Postnatal mastitis prophylaxis consists in teaching women the rules of breast
feeding and personal hygiene. Nipple crack and lactostasis are to be timely
detected and treated.
BREECH PRESENTATION
II. Tests and Assignments for Self-assessment.
Multiple Choice.
Choose the correct answer / statement:
1. What the type of presentation is if the buttocks and feet are palpable:
A - Frank breech presentation;
B - Complete breech;
C - Incomplete breech presentation;
D - Footling ;
E - Kneeling presentation.
2. What the type of presentation is if the feet are palpable than the buttocks:
A - Frank breech presentation;
B - Complete breech;
C - Incomplete breech presentation;
D - Footling;
E - Kneeling presentation.
3. What the estimated weight of the fetus is the indication | cesarean section?
A - 2500 g; B - 3000 g; C- 36OO g; D - 4000 g
4 What type of the manual aids need the patients with a footling?
A- Manual aid by Tsovyanov 1; B - Manual aid by Tsovyanov II; C - Classic manual aid; D -
Breech extraction.
5. What type of the manual aids need the patients with a frank breech presentation?
A- Manual aid by Tsovyanov I.
B- Manual aid by Tsovyanov II;
C - Classic manual aid;
D - Breech extraction.
7. Prirnipara F.,25 years old. Pregnancy at term. The labor started 6 hours later. The membranes
ruptured 1 hour ago. Pelvic sizes: 23,25,29,18 cm. Fetal head rate 140 per minute with
satisfactory characteristics. Uterine contractions are occurring every 7-8 minutes. Per vaginum:
the uterine cervix dilatation is 5 sm. The amniotisac is absent. One fetal foot is palpated in the
vagina. Buttocks are in the pelvic inlet. Diagnosis? How the delivery must be managed?
2. If there has been no descent of the presenting breech for over 1 hour during the second stage
of labor, and fetal heart rate is l00, the doctor should perform:
A - Breech extraction;
B - Cesarean section;
C - Any active procedure;
D - Destructive procedure.
3. Vaginal delivery of the term breech is generally avoided when the fetus weight is more of how
many grams?
A - 2500 - 3000;
B - 3000 - 3500;
C - 3500 - 4000;
D - 4000 - 4500.
Real-life situation to be solved:
4. 38-years-old women at term arrives in active labor, full dilated with a presenting part at the
pelvic floor. She has had no prenatal care and four previous vaginal deliveries of four boys all
weighing 3000 to 3200 g. Because there are variable decelerations and a questionable loss of
long term variability, artificial rupture of membranes is performed, at which time the patient is
found to have a frank breech presentation. The FHR is now reassuring. Contractions are strong,
occurring every 3 minutes. The fetal heart rate is 110 beat in minute. Which would be the best
management?
MALPRESENTATIONS
II. Tests and Assignments for Self - assessment.
Multiple Choice.
Choose the correct answer / statement:
1. Which is the most appropriate treatment for the woman on 34 week of gestation having an
oblique lie of the fetus? A - The classic version of the fetus; B - To stimulate delivery: C —
Cesarean delivery; D - External version of the fetus.
2- A 17-year-old patient at 39 weeks gestation presents to the hospital av'nga transverse lie of the
fetus. Which is the most appropriate treatment? A - External version of the fetus;
B - Rupture of the fetal membranes to stimulate delivery; C - Immediate cesarean delivery; D -
An immediate vaginal delivery.
3- What are the requirements for internal podalic version of the fetus? A - Normal temperature
of the body
B - Cervix must be fully dilated;
C - Membranes must be ruptured;
D - All of the above.
Real — life situations to be solved:
4. A multipara at 38 weeks of gestation entered the obstetrical department with normal labor
activity. Complaints of the cough, headache The temperature of the body is 38,7 °C. Pelvic sizes:
25-28-31-20. Expected weight of fetus is 3000 g. Fetal heart tones are normal. The presenting
part is not palpated upon the pelvic inlet. The head is situated in the left part of the uterus.
Vaginal examination shows: the cervix is completely dilated. The membranes are intact.
Shoulder of the fetus is palpated as a presenting part. Which is the most appropriate treatment?
III. Answers to the Self- Assessment.
1. D. 2. C. 3. D. 4. Labor, at term, second stage. Acute respiratory disease. Transverse fetal lie.
The most appropriate management is internal podalic version.
Students must know:
l. The determination of the operation of obstetrics versions.
2. The indications for obstetrics versions.
3. The conditions for the operation of obstetrics versions.
4. The techniques for the external and internal obstetrics versions.
5. Anesthesia for the operation.
6. The complications caused by obstetrics versions.
Students should be able to:
1. To make the external obstetric physical examination.
2. To make the internal obstetric physical examination;
3. To evaluate the indications and contraindications to obstetric versions.
4. To do the operations of the internal and external version on phantom.
DEFLEXED PRESENTATIONS
II. Tests and Assignments for Self - assessment.
Multiple Choice.
Choose the correct answer / statement:
1. What is the first movement of labor in face presentation? A — Internal rotation;
B — External rotation: C — Flexion: D - Extension.
2. What is the first degree of the head extension? A — Deflexed vertex presentation;
B — Breech presentation; C - Brow presentation; D - Face presentation.
3. What is the fixing point in the face presentation?
A - Occiput;
B - Sinciput;
C — Fossa suboccipitalis;
D - The area of the border of the hair part.
4. What is the leader point in the face presentation? A - Anterior fontanel;
B - Posterior fontanel; C — Chin.
D — Area of the border of the hair part. Real ~ life situations to be solved:
5. M., 28 years old, para 2. Full term of pregnancy. Initiation ot labQl was 8 hours ago. The
membranes ruptured 20 minutes ago. Fetal heart rate is 132 per minute with satisfactory
cter'istics. Per vaginum: the cervix is completely dilated. The amniotic is absent. Fetal head is in
outlet plane of pelvic. The chin is palpated under the symphysis.
Diagnosis? What is the moment of labor biomechanism ?
6. Primipara N.,25 years old. Delivery at term. The labor started 6 ago. The membranes ruptured
1 hour ago. Pelvic sizes: 25,28,31,20. Fetal head rate 140 per minute with satisfactory
characteristics. Uterine ntractions are occurring every 7-8 minutes. Per vaginum: the uterine
cervix dilatation is 6 cm. The amniotic sac is absent. Fetal head fixed to the inlet of pelvis.
Sagittal suture is in the right oblique size. Small and large fontanels are palpated. The large
fontanel is lower. Diagnosis?
III. Answers to the Self- Assessment,
1. D. 2. A. 3. C. 4. C. 5. Labor 2, at term, 2 period of labor. Face presentation. Third moment of
the labor biomechanism: flexion of the fetal head. Management: normal vaginal delivery. 6.
Labour 1, at term. 1 period of labor. The defiexed vertex presentation. Visual Aids and Material
Tools:
LMi Students must know:
1. The cardinal movements of labor in deflexed cephalic presentation.
2. The definition of deflexed vertex, brow and face presentation.
3. The mechanism of the head's flexion, rotation, extension, internal body's rotation and external
head's rotation.
4. The definition of the leader point and the fixing point. Students should be able to:
1. To make the external obstetric physical examination.
2. To make the internal obstetric physical examination.
3. To show the cardinal movements of labor in deflexed cephalic presentation on phantom.
4. To determine normal and pathological course of the labor.
CONTRACTED PELVIS
II. Tests and Assignments for Self - assessment.
Multiple Choice.
Choose the correct answer / statement:
1. What is the first movement of labor in face presentation? A — Internal rotation;
B — External rotation: C — Flexion: D - Extension.
2. What is the first degree of the head extension? A — Deflexed vertex presentation;
B — Breech presentation; C - Brow presentation; D - Face presentation.
3. What is the fixing point in the face presentation?
A - Occiput;
B - Sinciput;
C — Fossa suboccipitalis;
D - The area of the border of the hair part.
4. What is the leader point in the face presentation? A - Anterior fontanel;
B - Posterior fontanel; C — Chin.
D — Area of the border of the hair part. Real ~ life situations to be solved:
5. M., 28 years old, para 2. Full term of pregnancy. Initiation ot labQl was 8 hours ago. The
membranes ruptured 20 minutes ago. Fetal heart rate is 132 per minute with satisfactory
cter'istics. Per vaginum: the cervix is completely dilated. The amniotic is absent. Fetal head is in
outlet plane of pelvic. The chin is palpated under the symphysis.
Diagnosis? What is the moment of labor biomechanism ?
6. Primipara N.,25 years old. Delivery at term. The labor started 6 ago. The membranes ruptured
1 hour ago. Pelvic sizes: 25,28,31,20. Fetal head rate 140 per minute with satisfactory
characteristics. Uterine ntractions are occurring every 7-8 minutes. Per vaginum: the uterine
cervix dilatation is 6 cm. The amniotic sac is absent. Fetal head fixed to the inlet of pelvis.
Sagittal suture is in the right oblique size. Small and large fontanels are palpated. The large
fontanel is lower. Diagnosis?
III. Answers to the Self- Assessment,
1. D. 2. A. 3. C. 4. C. 5. Labor 2, at term, 2 period of labor. Face presentation. Third moment of
the labor biomechanism: flexion of the fetal head. Management: normal vaginal delivery. 6.
Labour 1, at term. 1 period of labor. The defiexed vertex presentation.
Students must know:
1. The cardinal movements of labor in deflexed cephalic presentation.
2. The definition of deflexed vertex, brow and face presentation.
3. The mechanism of the head's flexion, rotation, extension, internal body's rotation and external
head's rotation.
4. The definition of the leader point and the fixing point. Students should be able to:
1. To make the external obstetric physical examination.
2. To make the internal obstetric physical examination.
3. To show the cardinal movements of labor in deflexed cephalic presentation on phantom.
4. To determine normal and pathological course of the labor.
References:
VI. List of recommended literature
1. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994.
2. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. - Third Edition.- 1998.
3. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. -1993.
4. Clinical Obstetrics of Fetus and Mother – E. Albert Reece&John Hobbins. – Third Edition. –
Blackwell publishing. – 2007.
5. Obstetrics Illustrated. – Kevin P. Hanretty. – Sixth Edition. – Churchill Livingstone. - 2003.
6. Manual on Obstetrics. – Arthur T. Evans. – Seventh Edition. - Lippincott Williams & Wilkins.
– 2007